Court outcomes for clients referred to a community mental health court liaison service

International Journal of Law and Psychiatry 32 (2009) 92–100

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International Journal of Law and Psychiatry

Court outcomes for clients referred to a community mental health court liaison service Ketrina A. Sly, John Sharples, Terry J. Lewin ⁎, Christopher J. Bench Hunter New England Mental Health and the University of Newcastle, Australia

a r t i c l e

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Keywords: Community mental health services Crime Mental illness Court decisions Service audit

a b s t r a c t Court liaison and diversion services come in a variety of forms, but the similarities and differences between these services are not well characterized. Findings from a six-year audit of the Newcastle (Australia) Mental Health Court Liaison (MHCL) service are reported, including client characteristics, offence and service contact profiles, court outcomes, and interrelationships among these variables. During the audit period, there were 2383 service episodes by 1858 clients (1478 males, 380 females). Drug and alcohol disorders (40.9%) and psychotic disorders (17.0%) were the most prevalent mental health problems, while assault (23.1%), theft (23.1%), offences against justice procedures (15.4%), driving offences (13.4%) and malicious damage to property (8.3%) were the most frequently recorded charges. Among service episodes with a finalized court outcome, 70.0% involved a punishment (bond: 49.5%; jail term: 29.7%). Females were less likely to be punished, but more likely to have their case dismissed under sections of the relevant Act that required further assessment and monitoring. Being married, or having an adjustment or drug and alcohol disorder, were also associated with an increased likelihood of punishment, while clients with a psychotic or bipolar disorder were less likely to be punished. Among clients who were punished, those referred from inpatient mental health services were more likely to receive a non-jail punishment, while unemployed clients were more likely to be jailed. A substantial proportion of clients had court outcomes that required an ongoing involvement with local mental health services. By being part of community mental health services, our MHCL service is able to work efficiently and effectively with the criminal justice system, while facilitating ready access to existing mental health services and continuation of care. Crown Copyright © 2009 Published by Elsevier Ltd. All rights reserved.

1. Introduction Resource limitations have impacted on access to both criminal justice and mental health services (Greenberg & Nielsen, 2003; Hiday & Wales, 2003). For example, a lack of treatment alternatives (Abram & Teplin, 1991), compounded by low detection rates among remand prisoners (Birmingham, Mason, & Grubin, 1996; Brooke, Taylor, Gunn, & Maden, 1996), has contributed to high numbers of mentally ill offenders being arrested. Furthermore, elevated rates of serious mental illness (ranging from 5–15%) continue to be identified among prison populations in many countries, including Australia (Butler, Allnutt, Cain, Owens, & Muller, 2005), New Zealand (Brinded, Simpson, Laidlaw, Fairley, & Malcolm, 2001), the U.S. (Dvoskin & Steadman, 1989) and the U.K. (Brugha et al., 2005). A review of prison populations in 12 countries reported rates of psychotic illness, major depression and antisocial personality disorder several times higher than in the general population (Fazel & Danesh, 2002). The receipt of psychiatric treatment in prison has also been shown to vary with diagnosis, suggesting that overall disorder rates are beyond the capacity of most ⁎ Corresponding author. Centre for Brain and Mental Health Research, Hunter New England Mental Health and the University of Newcastle, Callaghan, N.S.W. 2308. Australia. Tel.: +61 2 49246643; fax: +61 2 49246608. E-mail address: [email protected] (T.J. Lewin).

prison services (Brinded et al., 2001). Locally, 43% of all prisoners screened from the State of New South Wales (NSW) met diagnostic criteria for a major mental illness (Butler et al., 2005). Conversely, a Western Australian record linkage study revealed that 24% of clients utilizing mental health services had an arrest record (Jablensky, 2004). 1.1. Court liaison and diversion services Considering the difficulties faced in providing mental health treatment in prison, court liaison and diversion programs are seen as a viable alternative (Greenberg & Nielsen, 2002). 1.1.1. The interface between criminal justice and mental health services The likelihood of entry into the criminal justice system has been associated with violence at the time of arrest, substance abuse, and frequent police contact, often involving petty offending or minor nuisance matters (Golding, Eaves, & Kowaz, 1989; Kennedy, Truman, Keyes, & Cameron, 1997; Robertson, Pearson, & Gibb, 1996). Some studies suggest that: members of the general population were less likely to be detained for the same offence than those with a mental illness (Hiday & Wales, 2003); repeat minor offenders were being charged due to prior appearances (Robertson et al., 1996); and court staff were identifying low numbers (14%) of those with a mental illness (Shaw, Creed, Price, Huxley, & Tomenson, 1999).

0160-2527/$ – see front matter. Crown Copyright © 2009 Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ijlp.2009.01.005

K.A. Sly et al. / International Journal of Law and Psychiatry 32 (2009) 92–100

1.1.2. Models and processes Court liaison and diversion models were developed, in part, to deal with the substantial numbers of mentally ill offenders within the criminal justice system, together with specialized police services and mental health courts. The twin goals are to channel offenders away from the criminal justice system (when appropriate) and into mental health treatment (Boccaccini, Christy, Poythress, & Kershaw, 2005; Grudzinskas, Clayfield, Roy-Bujnowski, Fisher, & Richardson, 2005; Steadman & Naples, 2005) and to reduce re-offending (Burvill, Dusmohamed, Hunter, & McRostie, 2003). Traditional models involve diversion to hospital, while other models include assistance to the court (e.g., assessment and management recommendations) or treatment and support within mental health or community services (Brett, 2003; Burvill et al., 2003; Draine & Solomon, 1999; Greenberg & Nielsen, 2002). Pre- and post-booking programs exist, with the former involving diversion prior to formalized charges and the latter diversion following arrest (Steadman & Naples, 2005). Collaboration between the justice, mental health and social service systems is seen as the key to success, ensuring continuity of care, particularly given the high rates of co-occurring substance abuse and homelessness (Grudzinskas et al., 2005). Court liaison and diversion services are also heavily reliant on referral to work effectively, as the typical offender will come into contact with several agencies (e.g., police, probation officers, solicitors, health workers) (Turnbull & Beese, 2000). Increased co-operation and availability of diversion resources has probably reduced the number of undetected cases of mental illness, including minor repeat offenders previously lost to the system (Turnbull & Beese, 2000). In NSW, the process of diversion involves relevant sections of the Mental Health (Criminal Procedures) Act (1990), with requests for psychiatric assessment made under Sections 32 or 33 (“Mental Health (Criminal Procedures) Act, 1990: New South Wales (Reprint 2),” 1997). Section 32 was amended by the Crimes Legislation Amendment Act (2002) to allow orders to be enforced for a period of six months, where any breach of conditions requires presentation to the court, allowing early intervention and potentially avoiding an escalation of offending behavior (Spiers, 2004). 1.2. Assessment of outcomes Diversion programs have been shown to result in positive outcomes for individuals, systems and communities (Steadman & Naples, 2005), with improved access to community based treatments and services likely to reduce arrests (Hiday & Wales, 2003). However, the impact of particular treatment practices on outcomes is less clear (Steadman & Naples, 2005). Some of the potential influences on program effectiveness include: continuity of care, improved follow-up care, and community supervision (Purchase, McCallum, & Kennedy, 1996); better differentiation of professional boundaries (Turnbull & Beese, 2000); and increased planning and resource availability (James, 1999). Whilst assertive community treatment is indicated, the full array of community services are rarely provided (Steadman & Naples, 2005). Ideal models provide a complete range of services, including: treating psychiatric symptoms and substance abuse; improving functioning; and meeting basic needs (Hiday & Wales, 2003). Integrated services are likely to provide an alternative to long-term hospitalization, enabling community re-entry of mentally ill offenders (Mohan & Fahy, 2006). 1.2.1. Comparisons between diverted and non-diverted clients The evidence detailing the effectiveness of programs is not extensive, different models may serve different clients (Draine, Blank, Kottsieper, & Solomon, 2005; Robertson et al.,1996), and individuals diverted may not be equivalent to those not diverted (Steadman & Naples, 2005). Studies among court-based programs report equivalent or better outcomes for diverted clients, including: improvements in independent living skills, reduced substance use (Cosden, Ellens, Schnell, Yamini-Diouf, & Wolfe, 2003); lower rates of re-arrest, violence, homelessness, psychiatric hospitalization (Lamb, Weinberger, & Reston-Parham, 1996); and less time

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spent in jail (Steadman, Cocozza, & Veysey, 1999). Jail- and communitybased diversion programs also report similar positive outcomes (Hoff, Baranosky, Buchanan, Zonana, & Rosenheck, 1999; Lamberti et al., 2001; Steadman & Naples, 2005). Beneficial outcomes of diversion into hospital care include: improved mental state and discharge planning (Geelan, Campbell, & Bartlett, 2001); positive health outcomes, continued contact with community services, and reduced re-offending (Rowlands, Inch, Rodger, & Soliman, 1996). Court liaison services are seen to be highly effective in accelerating diversion into hospital, avoiding lengthy remands in custody, without increasing public safety risk (Exworthy & Parrott, 1997; James, 1999; Steadman & Naples, 2005). Newer court diversion models addressing co-existing substance abuse, and those involving mandated programs, have also reported positive outcomes, including: higher engagement and retention rates; and decreased substance use (Broner, Maryl, & Landsberg, 2005; Broner, Nguyen, Swern, & Goldfinger, 2003). Even though mentally ill offenders represent a substantial proportion of prison and court populations, researchers continue to point to the lack of program effectiveness research (Schaefer & Stefancic, 2003; Steadman & Naples, 2005). Given the considerable variation across court liaison and diversion services, and in the interests of learning more from one another (e.g., about the potential development, implementation and evaluation of service models and changes), a useful starting point would be to carefully characterize each of the existing types of service, including: the diversity of mental illness and offending behaviors evident amongst clients; service engagement strategies and contact patterns; relationships with mental health and court outcomes; and the identification of subgroups requiring specific attention. The service audit reported here is the beginning of such a process and we encourage other agencies to do likewise and to share their approaches and findings. 1.3. The Newcastle Mental Health Court Liaison (MHCL) service The Newcastle MHCL service began in 1997 as a pilot project at the Newcastle court complex and was the first of its kind in NSW (Sharples et al., 2003). Unlike other more recent services, it is part of the local community mental health system. The service forms cooperative links between the mental health and criminal justice systems, providing reliable information exchange, assistance and advocacy for offenders already being treated by mental health services, and assessments and practical management options for persons appearing before the local Magistrates (or lower) Court with no prior mental health services contact. The service consists of a full-time Clinical Nurse Consultant and Administrative Officer, with staff specialist and trainee psychiatrists providing medical back up. Referrals largely come from the Legal Aid duty solicitor (public defender), who usually represents individuals in custody facing non-indictable charges (i.e., relatively minor charges that are able to be finalized in the Magistrates Court [local court]). Typically, the likelihood of current mental health problems is indicated by police reports, the person's general demeanor, or a history of prior contact with mental health and/or drug and alcohol services. Following an initial assessment, a management plan is formulated, and if the person appears to be mentally ill under the Mental Health Act (1990), an immediate transfer to hospital for further assessment is arranged (pursuant to S33 of the MHCP Act, 1990). More frequently, negotiations between the lawyer (‘solicitor’) and the magistrate result in the granting of bail, to allow further assessment and/or treatment in the community, after which the court is informed of the outcome. Being part of the local community mental health system, the MHCL service also receives referrals and requests for advice directly from other units within the mental health service, generally for clients with outstanding matters before the court. Consequently, the MHCL service also provides a community forensic role, which complements its court assessment function.

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1.4. Purpose of this study

2.4. Data analysis

The purpose of this study was threefold: 1) to undertake a six-year service audit of the Newcastle MHCL service, describing the characteristics of the clients referred and their patterns of contact; 2) to examine relationships between client characteristics and offence profiles; and 3) to explore the pattern of court outcomes obtained and associated relationships.

SPSS statistical software (Version 14.0; SPSS, Chicago, IL, USA) was used to analyze the aggregated datasets. Many of the statistics reported in this article are descriptive. For the univariate analyses, chi-square (χ2) tests and analyses of variance (ANOVAs) were used to examine associations with the categorical and continuous outcome variables, respectively. Logistic regressions were used to examine associations with the categorical outcomes whilst controlling for potential confounders, with Adjusted Odds Ratios (AOR) the preferred metric for reporting the magnitude of effects. A layered series of analyses was conducted to examine factors associated with the various outcomes. For example, among all service episodes with a finalized court outcome, those receiving any punishment were compared with those not punished; then, within the punished sub-group, service episodes were compared on the basis of punishment type. For these analyses, three-step hierarchical logistic regressions were used, with socio-demographic, clinical and offence related factors, and service episode type included at successive steps. As a partial control for the number of statistical tests, the threshold for statistical significance was set at p b 0.01.

2. Method 2.1. Service audit The service audit period comprised the first six years of operation of the Newcastle MHCL service (i.e., all clients referred from August 1997 and discharged on or before June 30th 2003). For convenience, service contact years were grouped on the basis of financial years (e.g., Year 6: July, 2002 to June, 2003). We use the term ‘service episode’ to refer to each discrete period of client contact with the service, which was usually associated with a separate set of criminal charges (from any previous service episodes) and typically lasted one to two months. Episode length was defined as the number of days between the first service contact for that episode and the MHCL service discharge date. There were 2383 service episodes during the audit period, of which 1858 (78.0%) were classified as an ‘initial episode’ (i.e., first period of MHCL contact) and 525 (22.0%) as a ‘subsequent episode’. For each service episode, we coded basic sociodemographic information (e.g., client's gender, age, country of birth, cultural background, marital and employment status), clinical and service episode details (e.g., contact and discharge dates, referral source, diagnoses, discharge destination), charge details (e.g., offences, times committed/charged) and court outcomes (e.g., punishment type and duration). ICD-10 diagnoses (National Centre for Classification in Health, 2002) were based on routine clinical assessments (as opposed to structured interviews), which were completed either by the MHCL service alone or in conjunction with clinical staff from the referring agency. 2.2. Classification of criminal charges The 19 offence categories originally used by the NSW Bureau of Crime Statistics and Research (Doak, Fitzgerald, & Ramsay, 2003) provided a basis for coding all criminal charges associated with each service episode (see Table 2 for the complete list of offence categories). These offence categories were also grouped into three overall offence types: 1) offences against people; 2) offences against property; and 3) offences against public order, which included offences against justice procedures (e.g., breaches of bail conditions, Apprehended Violence Orders [AVOs] and other judicial orders) and driving offences (e.g., driving whilst intoxicated). Service episodes were classified in terms of the presence or absence of each of these offence types, individual offence categories, and the number of charges (e.g., five counts of theft by an individual were recorded as five charges of that type). 2.3. Court outcome coding Outcome data are routinely provided by the local courts for all clients referred to the MHCL service. For each service episode, where available, several aspects of the court outcomes were coded, including: punishment received; charges dismissed; any supervision requirements; AVOs received; and warrants issued. Details of sentencing, including length and type of bond, jail term, weekend detention, and community service were also recorded. When a client was charged with multiple offences, it was generally not possible to establish a one-to-one correspondence between individual charges and court outcomes.

3. Results 3.1. Characteristics of the MHCL service clients Table 1 presents a breakdown of the 1858 initial service episodes during the audit period with respect to their associated client Table 1 Characteristics of the MHCL service clients: breakdown of the 1858 ‘initial service episodes’ during the audit period—Mid 1997 to mid 2003 (1478 males, 380 females) Characteristica

%

Gender Males Females

79.5 20.5

Age (years) 10–19 20–29 30–39 40–49 ≥ 50

11.4 39.8 30.3 12.8 5.7

Country of birth Australia Elsewhere

94.8 5.2

Culture Aboriginal or TSI Non-aboriginal

5.0 95.0

Marital status Single Married-defacto Separated-divorced

70.8 15.8 13.4

Employment status Employed (full- or part-time) Unemployed Pension or disability benefit Other (e.g., student, home duties)

7.5 68.5 19.5 4.5

a

Characteristica

%

Referral source Criminal justice system Inpatient MH units Community health or MH Family, friends or self Other

64.0 22.2 9.6 2.7 1.5

Primary diagnosis (ICD-10) Adjustment disorder Bipolar disorder Depression Drug and alcohol disorder Psychotic disorder Personality disorder Other diagnosis No diagnosis (other than legal circumstances) Additional comorbid drug and alcohol disorder

Charge profilesb Offences against people No offences One or more Offences against property No offences One or more Offences against public order No offences One or more Overall No offencesc (N = 201) One or more (N = 1629)

7.3 6.0 11.9 25.8 17.0 7.1 10.2 14.8

15.1

64.5 35.5 69.9 30.1 62.7 37.3 11.0 89.0

MH = Mental Health Service, TSI = Torres Strait Islander. Charges associated with the current service episode, classified as ‘offences against people’ (e.g., assault, robbery), ‘offences against property’ (e.g., theft, malicious damage), or ‘offences against public order’ (e.g., against justice procedures, driving offences). c Includes clients who were primarily seeking advice and those presenting as a consequence of earlier charges. b

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characteristics. The prototypical initial service episode was by a male (79.5%), aged 20–39 years (70.1%), who was Australian born (94.8%), from a non-aboriginal background (95.0%), and who was currently single (70.8%). The majority of service episodes were by persons in receipt of welfare benefits, either through unemployment (68.5%) or disability (19.5%). Most referrals were from the criminal justice system (64.0%) or inpatient mental health units (22.2%). Several categories of ICD-10 primary diagnoses were identified, with drug and alcohol (25.8%) and psychotic disorders (17.0%) being the most frequent. Comorbid drug and alcohol problems were noted in an additional 15.1% of presentations, such that 40.9% of all service episodes were by persons with a drug or alcohol problem. Approximately one in seven presentations (14.8%) did not have a current psychiatric diagnosis, although aspects of their current legal circumstances or other situational factors were often noted as stressors. Table 1 also presents charge profiles for the current service episode. Offences against people were recorded for 35.5% of service episodes, with an average of 1.22 charges per offender (SD = 0.69). The corresponding values for the other categories were: property-related offences (30.1%), 1.55 charges per offender (SD = 3.20); and offences against public order (37.3%), 1.42 charges per offender (SD = 1.33). Overall, 11.0% of MHCL service episodes were coded as ‘no offences’, comprising: clients with AVOs sought against them (N = 94, 46.8%); those primarily seeking advice (N = 68, 22.8%); and those presenting as a consequence of earlier charges or associated issues. Among current offenders, the mean number of charges per service episode (across all offence types) was 1.61 (SD = 2.19). 3.2. Service presentations Among the 1858 clients, 1481 (79.7%) had a single service episode, with the remaining 377 (20.3%) contributing a total of 902 service episodes. Comparisons between clients with multiple versus single service episodes revealed that the former group was more likely to have a psychotic disorder (23.3% vs. 15.3%, χ2(1) = 13.71, p b 0.001) and to be receiving a disability support pension (24.7% vs. 18.2, χ2(1) = 7.92, p b 0.01). There were no other socio-demographic, clinical or offence profile differences between these subgroups. Across the audit period, the mean number of service episodes per client was 1.64 (SD = 1.07).

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The typical length of an episode increased from 36.61 days (SD = 52.47; 202 episodes) in year 1 to 61.82 days (SD = 61.6; 485 episodes) in year 6. However, the rate of new presentations appears to have reached a plateau, with service demands growing primarily because of representations by previous clients (e.g., from 22 episodes in year 2 to 156 episodes in year 6). In the last year of the audit, one-third of episodes (32.2%) were by previous clients. 3.3. Patterns of offending Table 2 reports offence category profiles. The 1629 initial service episodes associated with an offence resulted in 2615 charges, while offences associated with the 464 subsequent service episodes resulted in 682 charges. The percentage of the total charges that related to the different offence categories was broadly similar for the initial and subsequent episodes. Among the initial service episodes: 30.3% of charges involved offences against people, with assault recorded most frequently (23.1%); one-third (32.5%) related to offences against property, of which 23.7% involved theft and 8.5% malicious damage; while offences against public order contributed the remaining 37.2%, with 13.8% related to offences against justice procedures and 13.6% to driving offences. There was also a significant increase in offences against justice procedures (largely associated with breaches of AVOs) from 13.8% of total charges initially to 21.7% for subsequent episodes (χ2(1) = 25.83, p b 0.001). 3.4. Pattern of court outcomes Finalized court outcome details were not available for all service episodes, with the major outcome analyses being based on 1522 episodes (68.3%) (excluding the 155 service episodes without a current offence). Among the 706 episodes without finalized outcomes, 187 (26.5%) had incomplete offence details, 288 (40.8%) had an unknown court outcome, and 231 matters (32.7%) were not yet finalized. Analyses undertaken to explore potential biases associated with court outcome status availability revealed a significant association with service year (χ2(10) = 142.23, p b 0.001). A higher likelihood of an unknown outcome, or incomplete offence details, was observed during the early years of the MHCL service. As the service's documentation procedures improved,

Table 2 Offence category profiles by service episode type (initial/subsequent) for the six-year audit period Offence category

Offences against people Homicide Assault Sexual offences Abduction and kidnapping Robbery Other offences against the person Offences against property Theft Demand money with menaces Extortion, blackmail Arson Malicious damage to property Offences against public order Drug offences Offensive behavior Prostitution offences Betting and gaming offences Weapons offences Against justice procedures Driving offences Other offences Total a

Initial service episodesa (N = 1629 clients)

Subsequent service episodesa (N = 343 clients)

Number of service episodes

Number of charges

Percentage of total charges

Number of service episodes

Number of charges

Percentage of total charges

650 19 486 51 4 56 45 550 403 3 1 4 158 683 84 24 1 0 50 329 219 23 1629

792 19 603 53 4 63 50 850 621 3 1 4 221 973 106 25 1 0 64 361 356 60 2615

30.3 0.7 23.1 2.0 0.2 2.4 1.9 32.5 23.7 0.1 0.04 0.2 8.5 37.2 4.1 1.0 0.04 0 2.4 13.8 13.6 2.3 (100.0)

170 4 134 3 1 10 20 147 104 1 1 1 46 201 17 4 0 0 10 134 48 1 464

206 4 159 3 1 12 27 198 141 1 1 1 54 278 24 5 0 0 15 148 85 1 682

30.2 0.6 23.3 0.4 0.1 1.8 4.0 29.0 20.7 0.1 0.1 0.1 7.9 40.8 3.5 0.7 0 0 2.2 21.7 12.5 0.1 (100.0)

Excludes service episodes where the client was primarily seeking advice (e.g., where there was no new charge associated with the current service episode).

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including the alliance with the criminal justice system, unknown court outcomes decreased (from 28.3% in year 1 to only 4.3% by year 6), with corresponding reductions in missing offence details (from 15.6% to 6.0%). Further analyses of court outcome status revealed an association with referral source (χ2(4) = 50.36, p b 0.001). The rate of finalized court outcomes was only 53.9% for referrals from inpatient psychiatric units compared to 65.8% to 72.2% for other services. Adjusting for year of presentation, there was still a significant association, with referrals from inpatient services being less likely to have a finalized outcome compared to those through the criminal justice system (Adjusted Odds Ratio (AOR)= 0.48, 99%CI: 0.35, 0.64, p b 0.001). Table 3 presents a breakdown of the finalized court outcomes by service episode type, with 70.0% of episodes resulting in a punishment and 28.3% a dismissal, which was significantly more likely to occur for subsequent episodes (36.8% vs. 25.8%, χ2(1) = 11.36, p b 0.001). However, reasons for dismissal were consistent across service episode types, with two-thirds (67.6%) being dismissed under S32/33 of the MHCP Act (1990). Among those punished, 49.5% received a bond, 29.7% a jail sentence, 18.1% a fine, 3.7% community service, and 1.3% weekend detention. Bonds issued for initial service episodes were more likely to involve supervision through the criminal justice system than those for subsequent episodes (96.7% vs. 88.9%, χ2(1) =10.85, p b 0.001), with a median bond length of 12 months regardless of episode type. Subsequent service episodes were also more likely to be associated with a jail term (37.8% vs. 27.8%, χ2(1) =8.09, p b 0.01), although the median jail term (6 months) was comparable. There was also a trend for fines to be of a higher amount when related to subsequent episodes (F(1,191) =4.24, p =0.04), although this may reflect general increases in fines over time. Among the 1522 episodes with a finalized outcome (and a current offence), there were 26 clients who only had an AVO granted against them. In addition, 103 AVOs were sought amongst clients with no current offence recorded, of which 68 (66.0%) were granted. 3.5. Factors significantly associated with outcome A series of three-step hierarchical logistic regression analyses was conducted to try to identify the factors associated with: punishment status, punished (N = 1066) vs. dismissed (N = 430); punishment type, jailed (N = 317) vs. other punishment (N = 749); dismissal type, MHCP Act (1990) (N = 286) vs. Crimes Act (N = 137); and bond type, supervised

by criminal justice system alone (N = 327) vs. in conjunction with mental health services (N = 173). The predictor variables in these analyses included: socio-demographic factors (Step 1: age, gender, marital and employment status); clinical and offence related factors (Step 2: referral source, primary diagnosis, substance use comorbidity status, and offence type); and service episode type (Step 3). Table 4 summarizes the results from the logistic regressions for three of the outcomes examined, while the analyses relating to bond type are reported in the text. As shown in Table 4, the likelihood of being punished was significantly lower for females (62.0% vs. 72.3%, AOR=0.61) but higher for those who were married (77.9% vs. 69.7%, AOR=1.73). Clients with adjustment (AOR=3.05) or drug and alcohol disorder (AOR=2.39) were more likely to be punished, while those with a psychotic (AOR=0.45) or bipolar disorder (AOR=0.40) were less likely. Non-significant trends were also observed for employment status, referral source and episode type. Clients receiving disability support were less likely to be punished (61.8% vs. 78.8%, AOR=0.51, p=0.02), as were clients referred from inpatient psychiatric units (60.0% vs. 75.8%, AOR = 0.66, p = 0.02) and those involved in subsequent service episodes (63.0% vs. 73.6%, AOR=0.72, p=0.03). The likelihood of receiving a jail sentence was significantly higher for clients who were unemployed (33.8% vs. 14.1%, AOR= 3.21) and lower for referrals from inpatient units (17.5% vs. 32.8%, AOR = 0.43). A nonsignificant trend was also observed for community mental health referrals, who were less likely to be jailed when compared to criminal justice system referrals (16.9% vs. 32.8%, AOR= 0.47, p = 0.02). Clients were also more likely to be given a jail sentence for subsequent compared to initial service episodes (37.8% vs. 27.8%, AOR= 1.63). Nonsignificant trends were observed for gender and age, with females less likely to be jailed (20.6% vs. 31.5%, AOR = 0.59, p = 0.02) and clients aged 20–39 more likely than those aged 10–19 years to receive a jail sentence (32.8% vs. 24.4%, AOR= 1.88, p = 0.02). Bond supervision type (criminal justice vs. joint supervision with mental health service) was not significantly associated with demographic or referral characteristics. However, non-significant trends were observed for diagnosis, with the likelihood of receiving joint supervision increasing for diagnoses of bipolar disorder (59.1% vs. 31.3%, AOR = 3.31, 99%CI: 0.81, 13.60, p = 0.03) or a psychotic disorder (46.5% vs. 31.3%, AOR = 2.40, 99%CI: 0.87, 6.64, p = 0.03) compared to no diagnosis. Conversely, the likelihood of having charges dismissed under S32/33 of the MHCP Act (1990), as opposed to the Crimes Act,

Table 3 Court outcomes by service episode type (initial/subsequent) for the six-year audit period Court outcomea Punished, N (%) Bond, N (% of punished) Mean length, years (SD) Supervision status % Unsupervised % Criminal Justice (CJ) % CJ & Mental Health Service Jail, N (% of punished) Mean length, months (SD) Weekend detention, N (% of punished) Mean length, weeks (SD) Fine, N (% of punished) Mean dollars, $AUS (SD) Community service, N (% of punished) Mean length, hours (SD) Dismissed, N (%) S32/33, MHCP Act, N (% of dismissed) Crimes Act, N (% of dismissed) AVO Granted, N (%)

Finalised court outcomeb (N = 1522 episodes) Initial service episode

Subsequent service episode

Total

857 (72.1%) 428 (50.1%) 1.42 (0.65)

209 (62.6%)⁎⁎ 99 (47.4%) 1.44 (0.73)

1066 (70.0%) 528 (49.5%) 1.43 (0.67)

14 (3.3%) 274 (64.3%) 138 (32.4%) 238 (27.8%) 10.71 (28.12) 14 (1.6%) 25.21 (13.26) 165 (19.3%) 440.38 (236.02) 33 (3.9%) 104.24 (55.68) 307 (25.8%) 200 (66.4%) 101 (33.6%) 24 (2.0%)

11 (11.1%) 53 (53.5%)⁎ 35 (35.4%) 79 (37.8%)⁎ 6.37 (6.85) 0 0 28 (13.4%) 548.93 (364.09) 6 (2.9%) 148.33 (135.71) 123 (36.8%) 86 (70.5%) 36 (29.5%) 2 (0.6%)

25 (4.8%) 327 (62.3%) 173 (33.0%) 317 (29.7%) 9.60 (24.56) 14 (1.3%) 25.21 (13.26) 193 (18.1%) 456.14 (260.17) 39 (3.7%) 111.03 (72.76) 430 (28.3%) 286 (67.6%) 137 (32.4%) 26 (1.7%)

Statistically significant difference from initial service episodes: ⁎p b 0.01, ⁎⁎ p b 0.001. a MHCP = Mental Health (Criminal Procedures) Act, 1990. AVO = Apprehended Violence Order. b Excludes service episodes without a finalised court outcome (including those with no current offence, incomplete offence details and an unknown outcome).

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Table 4 Predictors of punishment status (punished vs. dismissed), punishment type (jailed vs. other), and dismissal type (MHCP vs. Crimes Act)a Statistically significant Predictor variables Gender Males Females Marital status Single Married–defacto Divorced–separated Other Employment Employed FT or PT Unemployed Disability support/pension Other (student/home) Referral source Criminal justice system Inpatient MH units Community health or MH Family, friends or self Primary diagnosis (ICD-10) Adjustment disorder Bipolar disorder Depression Drug and alcohol disorder Psychotic disorder Personality disorder Other diagnosis No diagnosis Episode type Initial Subsequent

Punishment status

Punishment type

% Punished

AOR

73.3 62.0

1.00 0.61

69.7 77.9 72.3 66.7

1.00 1.73

78.8 74.0 61.8 66.7

1.00

75.8 60.0 58.5 57.1

1.00 0.66

#

(0.48, 1.03)

88.5 44.8 76.3 85.5 50.0 72.2 73.5 70.4

3.05 0.40

⁎ ⁎

(1.19, 7.83) (0.19, 0.85)

2.39 0.45

⁎⁎ ⁎⁎

(1.36, 4.20) (0.26, 0.79)

1.00

73.6 63.0

1.00 0.72

0.51

(99%CI)

% Jailed

AOR

⁎⁎

(0.42, 0.89)

31.5 20.6

1.00 0.59

⁎

(1.09, 2.7)

#

#

(0.25, 1.04)

(0.49, 1.05)

Dismissal type

#

(99%CI)

% MHCP

AOR

(0.35, 1.01)

65.0 76.0

1.00 2.12

70.9 65.3 49.0 60.0

1.00

52.4 64.2 78.3 57.9

1.00

30.2 30.6 25.0 40.0 14.1 33.8 21.0 31.6

1.00 3.21

⁎⁎

(1.35, 7.62)

3.24

#

(0.93, 11.29)

32.8 17.5 16.9 32.1

1.00 0.43 0.47

⁎⁎ #

(0.22, 0.84) (0.21, 1.05)

38.8 12.8 24.5 33.3 31.3 21.9 23.1 32.8

0.35

#

(0.87, 1.38)

27.8 37.8

1.00 1.63

⁎

(1.04, 2.55)

1.00

0.23

2.83

(99%CI)

⁎

(1.01, 4.42)

⁎⁎

(0.09, 0.60)

#

(0.75, 10.62)

62.9 74.4 77.6 70.0 50.0 78.7 60.6 49.2 80.8 55.6 63.2 61.1 66.4 70.5

a Tabled values show the percentage of each subgroup with the designated court outcome, the Adjusted Odds Ratios (AOR) from the three-step logistic regression analyses, the significance of the corresponding Wald statistics (⁎p b 0.01, ⁎⁎p b 0.001), and the associated 99% confidence intervals (99%CI). The reference subgroup for each predictor variable is indicated by an AOR of 1.0. Results are reported for predictor variables that were statistically significant or approaching significance (# p b 0.05).

increased significantly for females (76.0% vs. 65.0%, AOR = 2.12). Separated or divorced clients were also less likely to have charges dismissed under S32/33, compared to single clients (49.0% vs. 70.9%, AOR = 0.23). A non-significant trend for employment was also observed, with clients receiving disability support having more than twice the relative odds of being dismissed under S32/33 (78.3% vs. 52.4%, AOR = 2.83). 4. Discussion 4.1. Client profiles Client characteristics identified through the audit were similar to those reported elsewhere (Barnes, Hudson, & Roberts, 2000; Burvill et al., 2003; Purchase et al., 1996), with service episodes typically involving clients who were single, male, aged 20–39 years, receiving unemployment or other welfare benefits, and who were referred from the criminal justice system. Only a small percentage (5.0%) of clients were indigenous, which was consistent with regional demographic profiles and with other Australian diversion programs (Burvill et al., 2003). However, indigenous males are often over-represented in prison populations (Butler et al., 2005), suggesting that there may be some barriers to indigenous clients accessing diversion programs (Burvill et al., 2003). On the other hand, the rate of unemployment in our sample was ten times the local rate (of 6.8% for the September quarter, 2004). Drug and alcohol and psychotic disorders were the most frequently recorded diagnoses, consistent with previous research among offenders with a major mental illness (Barnes et al., 2000; Burvill et al., 2003; Purchase et al., 1996) and with trends among other court liaison schemes (Orr, Baker, & Ramsay, 2007). The Newcastle MHCL service is unique in that it accepts referrals from the criminal justice system and directly from within mental health services, which is illustrated by the finding that 11.0% of clients

did not have any charges associated with their current service episode and were primarily seeking advice (often about AVOs sought against them). The majority of clients (79.9%) had a single service episode, while those with multiple episodes were more likely to present with a psychotic disorder and to be receiving disability support. Similar representation patterns have been reported previously. For example, based on data from two post-booking diversion programs, over 18 months, 79% of clients were recorded as being diverted once, leaving around one-fifth with two or more diversions to the same service (Boccaccini et al., 2005). Little research has been undertaken among clients with multiple diversions or how they compare with those accessing mental health treatment through other pathways (Boccaccini et al., 2005). A more thorough examination of clients with repeated service presentations is a potential area for further investigation among existing court liaison programs. Overall, broadly similar rates were found for offences against property, people and public order. In total, there were 3297 charges recorded (see Table 2), with the most frequent being: assault (762 charges, 23.1%); theft (762 charges, 23.1%); offences against justice procedures (509 charges, 15.4%); driving offences (441 charges, 13.4%); and malicious damage to property (275 charges, 8.3%). A similar offence profile has been reported by other services (Burvill et al., 2003; Purchase et al., 1996), however, Burvill et al. (2003) reported lower rates of offences against people. Approximately half of the episodes involving offences against public order related to offences against justice procedures (463/884 episodes, 52.4%), which have been identified previously as over-represented among MHCL clients, compared to all offenders from the same region (Sharples et al., 2003). Other studies have found that detainees are often arrested for public disorder or non-notifiable offences, with repeat minor offenders at higher risk of circulating in and out of the criminal justice system without the benefit of care (Robertson et al., 1996). The Newcastle MHCL service is attempting to close this gap by providing a

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high level of support to clients with offences against justice procedures. The observed higher percentage of charges within subsequent service episodes relating to offences against justice procedures (21.7%) suggests that the need for such support is likely to grow.

mental health services having a lower likelihood of receiving a jail term. Finally, after controlling for all other demographic and clinical characteristics, episode type continued to significantly predict the likelihood of receiving a jail sentence, which was more likely to be issued for a subsequent service episode.

4.2. Outcomes and associated characteristics 4.3. Limitations, service implications and future directions Although finalised court outcome details were not available for almost one-third of service episodes, there was no evidence to suggest that there were major data biases. Moreover, improvements in documentation procedures were observed, with a higher likelihood of clients having complete offence details and court outcomes during more recent years. However, a lower rate of finalised outcomes was noted among clients referred from inpatient psychiatric units, which may partially reflect the discretionary powers of the police (e.g., deciding not to proceed with some matters relating to hospitalized clients). Similarly, decisional discretion by the police or other agencies may impact on arrest and referrals patterns. Among the 68.3% of service episodes with a known court outcome, a dismissal rate of 28.3% was observed. Female clients had approximately twice the relative odds of dismissal under S32/33 of the MHCP Act (1990) (as opposed to the Crimes Act), while divorced or separated clients were less likely to be dismissed under S32/33 (see Table 4). While the factors underlying the latter association are unclear, the association with gender could reflect a judicial trade-off, with females being less likely to be punished (62.0% vs. 73.3%) but more likely to be assessed and monitored under a S32/33 dismissal (76.0% vs. 65.0%). Among service episodes with a known court outcome, 70.0% involved a punishment of some kind. Relatively few clients received weekend detention (1.3%), community service (3.7%) or a fine (18.1%), with a bond (49.5%) being the most frequent punishment, followed by a jail sentence (29.7%). Similar profiles have been reported among a South Australian Magistrates Court diversion sample, with 70% of offences with a final determination resulting in a guilty finding (with or without a conviction recorded), 17.3% being dismissed or not proceeded with, 6.5% involving AVOs, and 5.3% left un-finalised (Burvill et al., 2003). By comparison, low rates of arrest and jail term outcomes have been reported among clients of formal (police-based) prebooking U.S. diversion programs (ranging from 2–13%) (Lamb, Shaner, Elliott, DeCuir, & Foltz, 1995; Steadman, Deane, Borum, & Morrissey, 2000). Unfortunately, because of fundamental differences between diversion models (and in discretionary powers), direct international comparisons are difficult. Community service orders had a low rate of utilisation, compared with their popularity elsewhere, presumably because magistrates perceived that the likelihood of compliance was low among this group, given their general levels of symptomatology and relative absence of social supports. Several factors were significantly associated with the likelihood of being punished, with females and married clients being more likely to receive a punishment. Clients with an adjustment or drug and alcohol diagnosis had two to three times the relative odds of receiving a punishment compared to those with no diagnosis, while clients with a psychotic or bipolar disorder had a decreased likelihood of being punished. These findings are not dissimilar to those previously reported among court liaison samples, where clients with a psychotic or bipolar disorder have tended to be hospitalized while those with a diagnosis of major depression, substance abuse/dependency or an antisocial personality disorder were more likely to remain in the criminal justice system (Barnes et al., 2000). Employment status was among the factors significantly associated with the type or severity of punishment received, with unemployed clients having around three times the relative odds of receiving a jail sentence. Unemployment appears to be an important issue, irrespective of type of offending, with previous research supporting its significant impact on outcome (Robertson et al., 1996). Referral source was also associated with punishment type, with clients referred from

The current study was a naturalistic, service evaluation project and not a formal research endeavor. Therefore, the extent and quality of the data collected needs to be viewed against the backdrop of the clinical and administrative needs and resources of the service being audited. On the other hand, a six-year audit, albeit from a single service, provides a substantial snapshot of client characteristics, offence profiles, and court outcomes. Engaging a sample of clients in the research process, using formal survey and/or interview based assessments, may have strengthened the study, but our ongoing, service based involvement with these clients has provided an opportunity to identify issues and potential constraints on the study's findings. Additionally, we were unable to characterize clients who were not diverted to the MHCL program. Previous research has revealed a number of factors, including history of previous convictions, gender and age, that are associated with the likelihood of diversion or referral (Draine et al., 2005; Luskin, 2001). Draine et al. (2005) suggests that diversion of acutely ill individuals only marginally engaged in treatment (at the time of first criminal justice contact) may provide an avenue for treatment, perhaps resulting in diversion from deeper criminal justice system involvement. Although the needs of clients were not formally assessed, the service audit highlighted many of the issues that need to be considered. The strengths of the current integrated community mental health service model were apparent, at least in terms of efficiency. Despite modest staff numbers, support was able to be provided to a relatively large catchment area, with substantial referrals from both criminal justice and mental health services. Working collaboratively with the criminal justice system, while being based within community mental health services (i.e., an integrated model), allowed ready access to existing mental health services and continuation of care. The 70% increase in the length of service episodes observed across the six-year audit probably reflects changed practices within both the courts and mental health services, with a greater focus on assessments, treatment programs and monitoring. The finding that offence type was not associated with the court outcomes examined, whilst selected socio-demographic and clinical variables were (e.g., see Table 4), highlights the important role of antecedent, contextual and personal factors in judicial decisionmaking and further reinforces the need for court liaison and diversion services to have ready access to mental health expertise and treatment services. The Newcastle MHCL service also fulfilled a genuine liaison function in that it provided relevant information and guidance about both the mental health and criminal justice systems and, where necessary, helped clients to translate and integrate information from both systems. The observed higher dismissal rate for subsequent service episodes could reflect the role of the MHCL service in providing adequate support for pre-existing clients (e.g., in establishing a mental health diagnosis and treatment alternatives). However, the potential consequences for clients re-presenting to the service (and the courts) also appear to be more polarized. For example, although subsequent episodes were associated with a lower likelihood of punishment (62.6% vs. 72.1%) (perhaps, reflecting the proportion with psychosis), among those who were punished, there was a higher likelihood of being jailed (37.8% vs. 27.8%). Therefore, a more complex set of pressures may surround repeat presenters to the service. From the perspective of the MHCL service, a substantial proportion of clients had court outcomes that required an ongoing involvement

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with local mental health services. For example, one-third of bonds issued specified joint supervision and two-thirds of dismissals were made under S32/33 of the MHCP Act (1990), which now includes a sixmonth period of enforcement. More generally, the courts are tending to play a more active role in mandating the need for treatment and in monitoring compliance. The longer-term impact of orders under S32/ 33 is also worth investigating, including relationships with subsequent re-offending and court and mental health outcomes. The data reported here should also provide a useful reference base, against which to compare data collected subsequent to the recent amendments to S32/33 enforcement provisions. The usage of psychiatric bail provisions has been described as effective in both providing magistrates with a viable alternative to remanding a client into custody, as well as linking them to other services (Kennedy et al., 1997). Finally, while the MHCL service audit substantially improved our understanding of client characteristics and potential linkages between court outcomes and socio-demographic, offending and clinical characteristics, this represents but the first, preliminary step. Within the scope of this project, it was not possible to address the mental health outcomes of clients or relationships between court outcomes, treatment engagement and compliance, and subsequent mental health and offending status. Future directions should include an examination of community-based treatments, hospital re-admissions and overall service utilization. Burvill et al. (2003) explored the extent of new service involvement among their clients and found 95% were already involved with service agencies or practitioners on referral, although one-third initiated contact with a new agency as part of their intervention plan, whilst maintaining existing service links. A more intensive examination of the illness, offending and treatment trajectories of some of the larger subgroups identified by our service audit would be worthwhile, selected either on the basis of clinical characteristics (e.g., psychosis or substance use problems) or offence profiles (e.g., offences against justice procedures). The subgroup of repeat service presenters who account for a disproportionately large number of service episodes (and associated resources), would also be worthy candidates for further research and for more intensive interventions to improve functioning and reduce re-offending. Acknowledgments The authors would like to thank: Hunter New England Mental Health; Audrey Reeves, from the MHCL service, for her administrative support and contribution to data coding; Lukman, a post-graduate student from the University of Newcastle, for assistance with coding the court outcome data; Tony Druce, for his assistance with electronic access to clinical service data; Paul Ruse, clerk of the Newcastle court, and his staff; and Greg Coles, Vaughan Carr, Russell Hinton and Pat Johnston for their contributions to earlier phases of this ongoing service evaluation research. References Abram, K. M., & Teplin, L. A. (1991). Co-occurring disorders among mentally ill jail detainees: Implications for public policy. American Psychologist, 46, 1036−1045. Barnes, M. T., Hudson, S. M., & Roberts, J. M. (2000). Characteristics of criminal defendants referred for psychiatric evaluation. New Zealand Journal of Psychology, 29, 61−65. Birmingham, L., Mason, D., & Grubin, D. (1996). Prevalence of mental disorder in remand prisoners: Consecutive case study. British Medical Journal, 313, 1521−1524. Boccaccini, M. T., Christy, A., Poythress, N., & Kershaw, D. (2005). Rediversion in two post-booking jail diversion programs in Florida. Psychiatric Services, 56, 835−839. Brett, A. (2003). Psychiatry, stigma and courts. Psychiatry, Psychology & Law, 10, 283−288. Brinded, P. M. J., Simpson, A. I. F., Laidlaw, T. M., Fairley, N., & Malcolm, F. (2001). Prevalence of psychiatric disorders in New Zealand prisons: A national study. Australian & New Zealand Journal of Psychiatry, 35, 166−173. Broner, N., Maryl, D. W., & Landsberg, G. (2005). Outcomes of mandated and nonmandated New York City jail diversion for offenders with alcohol, drug, and mental disorders. The Prison Journal, 85, 18. Broner, N., Nguyen, H., Swern, A., & Goldfinger, S. (2003). Adapting a substance abuse court diversion model for felony offenders with co-occurring disorders: Initial implementation. Psychiatric Quarterly, 74, 361−385.

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